Free Motion for Leave to Proceed in forma pauperis - District Court of Delaware - Delaware

.~? Case 1 :08-cv-00040-SLR Document 1 Filed 01/18/2008 Page 1 of 2
AO 240 {Rev. IO/D3]
DELAWAJlE£Rev. 4/Oil
UNITED STATES DISTRICT COURT
DISTRICT OF DELAWARE
,:Q_·z0°g|g‘=J bi
b0$>\'\ ltoverclel
Piamiirr APPLICATION TO PROCEED
\ L A EV, WITHOUT PREPAYMENT OF
ci 9 _ Defendant(s) _ _
` CASE NUMBER: Q
I, GBM Q,—o¤‘.:Zr@i¤l~‘? Mita W tg declare that I am the (check appropriate box)
m PBtll§lOI]€ff MOV3Ht lj Other y r·»~ -- re ...`. A ..-· rvrrrr. ~:-_ ,,, _ · ~ ___,_ __
in the above—entitIed proceeding; that in support of my request to proceed with ut p `'``1 ii. ui er
28 USC §l9l5, I declare that I arn unable to pay the costs of these proceedi gs . ga malkkam entitleij to he ief
sought in the complaint/petition/motion. tl li. i B timii `
i a e
i tc,....... m,:w,,,,,,,,
_ .S.DlSi°RiCl`COUHT i
In support of this application, I answer the following questions under penalty E. oi, i H
1. Are you currently incarcerated? Qui; El No (If "No" go to Question 2) CU PH.
>
If "YES" state the place of your incarceration I
Inmate Identification Number (Required); I Ogg
Are ou employed at the institution? {JG Do you receive any ayment from the institution? A/E)
Y t P Tm
Attach a ledger sheet Qom the institution of your incarceration showing at least the gast six months ’
transactions
2. Are you currently employed? III Yes Q
a, If the answer is "YES" state the amount of your tal and give the name and address of your employer.
b. If the answer is "NO" state the date of your last employment, the amount of your ta.ke—home
salary or wages and pay period and the name and address of your last employer.
3. In the past l2 twelve months have you received any money from any of the following sources? I
a. Business, profession or other self—employment El Yes o
b. Rent payments, interest or dividends El Yes Z?
c. Pensions, annuities or life insurance payments El Yes A No
d. Disability or workers compensation payments El Yes Bf No
e. Gifts or inheritances El Yes JQ/*No
f. Any other sources El Yes ¤ No
i../l
If the answer to any ofthe above is "YES" describe each source of money and state the amount
received AND what you expect you will continue to receive.

* Case 1 :08-cv—OOO40-SLR Document 1 Filed O1/18/2008 Page 2 of 2
AO 240 Reverse [Rev. 10/03) l
DELAWARE !R.ev, 4r'05
4. Do you have any cash or checking or savings accounts? El Yes 4%
l if "Yes" state the total amount $
5. Do you own any real estate, stocks, bends, securities, other financial instruments, automobiles or other
valuable property?
U Yes lil ~No""".
If “Yes" describe the property and state its value.
6. List the persons who are dependent on you for support, state your relationship to each person and
indicate how much you contribute to their support, OR state NONE if applicable.
I é " Da aj·v%'r/
I declare under penalty of perjury that the above infomation is true and correct.
j idhétqpi J 3, 2 ODS]
DATE SIGNATURE OF APPLICANT ·
NOTE TO PRISONER: - A Prisoner seeking to proceed without prepayment of fees shalI submit an
affidavit stating all assets. In-addition, a prisoner must attach a statement certified by the appropriate
institutional officer showing all receipts, expenditures, and balances during the last six months in your
institutional accounts. If you have multiple accounts, perhaps because you have been in multiple
institutions, attach one certified statement of each account.

Case 1:08-cv-00040-SLR

Document 1

Filed 01/18/2008

Page 1 of 2

Case 1:08-cv-00040-SLR

Document 1

Filed 01/18/2008

Page 2 of 2